For many years, governments and non-governmental
organizations have promoted an “ABC” approach to preventing HIV/AIDS. “ABC”
stands for Abstain from sex until marriage, Be faithful to a single partner,
and use a Condom every time you have sex. That’s all certainly good advice, and
if we can get more people to follow it, we will reduce the spread of HIV, the
virus that causes AIDS.

But is ABC the whole story? Is it the best we can do? ABC
has some known limitations. This video discusses those limitations and
additional things we can do to prevent the spread of HIV.

One problem with ABC is that it assumes that a person has
control over their own body and the ability to get help if their rights are
violated. Obviously, if a person is in a culture where they do not have equal
rights, they may not be able to follow the ABC guidelines. This often happens
to women in cultures where gender inequality is the norm. For example, women
may contract HIV through rape, marital rape, or their husband’s infidelity.
Women may be unable to flee an abusive marriage for fear of poverty and
starvation or of losing their children. These problems are discussed in more
detail in a video called “Ending Gender Inequality: A Key to Stopping HIV.”

Because of these realities, a broader acronym was recently
developed called S.A.V.E.[1] This means Safer practices, Access to
antiretroviral medications, Voluntary counseling and testing, and
Empowerment/Education. Let’s talk about what each one of these things mean.

“Safer practices” encompasses some parts of the ABC message.
For example, choosing abstinence until marriage, being faithful to a single
partner, and using a condom every time you have sex are all examples of safer
practices that are better than alternatives like unprotected sexual activity.
However, SAVE recognizes that ABC isn’t a message that is helpful to women and
girls who aren’t able to control whether they have sex, who they have sex with,
under what conditions they have, whether condoms are used, and whether their
partner is honest with them about their fidelity.

“Access to antiretroviral medications” recognizes that for
people who are already HIV positive or for risk reduction of the HIV negative
partner of those already positive, it’s crucial that antiretroviral medications
(ARVs) be made readily available to all who need them. Making ARVs readily available
is critical to stopping the spread of HIV. People treated with ARVs have lower
viral loads, are less infectious, and are therefore less likely to transmit HIV
to others.

Voluntary counseling and testing recognizes the need for
ensuring that all individuals in every country have access and encouragement to
be counseled in the modes of transmission of HIV. Additionally, it recognizes
the need for access to testing. If everyone were aware and educated about the
modes of transmission of HIV, in addition to emphasis on stigma reduction and
testing with universal access to ARVs and nutrition, it would be a great step
forward for HIV prevention.

Reducing HIV stigma will in turn make individuals more
willing to be tested. Experience has shown that when testing is available but
treatment is not, people are unlikely to seek testing because they see possible
consequences such as stigma, discrimination, and domestic violence if they are
test positive but no possible benefits. When people know that if they test
positive, they can get treatment that will prolong their life, they are more
likely to seek testing.

“Education/Empowerment” recognizes that awareness and
knowledge, combined with the ability to act on it reduces the spread of
HIV/AIDS. People need education about HIV so they understand how it is
transmitted, how to reduce their risk, how and why to get tested, and that
there is treatment. Broad-based education is also necessary to reduce cultural
stigma about HIV. But education alone is not enough. Education won’t help you
if you don’t have control over whether you have sex, with whom, and on what
terms.

Education/Empowerment is also part of another “Beyond ABC”
approach known as “DEF” for Disclosure in safety, Education/empowerment, and
Female-controlled prevention methods.[2]

Women in particular often fear that if they disclose their
HIV-positive status to their partner or husband, they may suffer harm as a
result. They fear consequences like domestic abuse, being ejected from the
household, losing their children, being ostracized in their community, losing
their job, and loss of family support—even if they were faithful to their
husband and infected by him! Steps like training police and law enforcement
officials on the links between HIV/AIDS and domestic violence, ensuring that
there is a functioning legal system people have confidence in, and providing
shelters for women who fear domestic violence can all help create an
environment that enables disclosure in safety.

Female-Controlled Prevention Methods

The condom is the most effective tool we have for preventing
HIV transmission during sexual activity such as vaginal, oral, and anal sex.
Unfortunately, a condom can’t be used without the man’s knowledge and
cooperation. This means that a woman who is in a sexual relationship with a man
who refuses to use a condom is unable to use the most effective barrier method
to protect herself from infection. It would be a great step forward if there
were proven female-controlled methods for reducing the risk of HIV
transmission. There are ongoing trials in various phases that are determining
the effectiveness of technologies such as microbicides for preventing HIV
transmission.[3]

Medically Performed Male Circumcision (With Counseling)

Studies in 2005 and 2006 have shown that medically performed
male circumcision is a safe and effective way of reducing a man’s risk of
contracting HIV through heterosexual intercourse.[4] Trials
in Uganda, Kenya, and South Africa showed risk reductions of 48 percent, 53
percent, and 60 percent respectively. It is important to note that these trials
only demonstrated a reduced risk that men would acquire HIV through
heterosexual sex. It has not been proven whether there is a risk reduction for
a man’s female partner and if so, how much. It is also unknown whether
circumcision reduces the risk of HIV transmission during anal sex between men.
Circumcision is definitely no guarantee against HIV infection and is no
substitute for safer practices like using a condom. Circumcised men must
continue to use condoms just like uncircumcised men for their own protection
and for the protection of their partner. However, medically performed male circumcision,
accompanied by appropriate counseling about the need for continued safer sex
practices, is clearly one more tool we can use to slow the spread of HIV,
particularly in areas such as Africa where there is a heterosexual epidemic of
HIV and access to condoms can be limited.

Significantly slowing the spread of HIV will require not
only the ABC approach, but also additional methods such as the ones we have
discussed in this video. By focusing on testing and access to ARVs, education
and empowerment to those at risk, and the use of newer methods and techniques
to reduce transmission, we will help prevent the further spread of HIV/AIDS.
This is [PRESENTER NAME].

This script was reviewed for accuracy and approved by
Becky Kuhn, M.D. on June 23, 2007.

References:

Jha, Alok. "Taking prevention of AIDS beyond ABC:
British doctors lead European search for microbicides to stop transmission of
HIV." 22 March 2004 Guardian.
http://www.guardian.co.uk/uk_news/story/0,3604,1174871,00.html

[3]Alok Jha, "Taking prevention of
AIDS beyond ABC: British doctors lead European search for microbicides to stop
transmission of HIV," 22 March 2004 Guardian.
http://www.guardian.co.uk/uk_news/story/0,3604,1174871,00.html